Provider Demographics
NPI:1689994246
Name:WATSONVILLE MEDICAL CLINIC AND AESTHETIC CLINIC, INC
Entity Type:Organization
Organization Name:WATSONVILLE MEDICAL CLINIC AND AESTHETIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:GERARDO
Authorized Official - Last Name:MAR
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:831-722-8787
Mailing Address - Street 1:284 PENNSYLVANIA DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3768
Mailing Address - Country:US
Mailing Address - Phone:831-722-8787
Mailing Address - Fax:831-722-8881
Practice Address - Street 1:284 PENNSYLVANIA DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3768
Practice Address - Country:US
Practice Address - Phone:831-722-8787
Practice Address - Fax:831-722-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13256OtherPHYSICIAN ASSISTANT NUMBER